DSM5577 - SECTION 8: SIGNIFICANT NEW DIAGNOSES INTRODUCED INTO THE DSM-5
Section VIII: Significant New Diagnoses Introduced into the DSM-5
Introduced: New Substance Use Disorders
Caffeine Withdrawal (ICD-10: F15.93)
Cannabis Withdrawal (ICD-10: F12.288)
Tobacco Use Disorder (ICD-10: Z72.0)
In the DSM-5, there are three new disorders related to substance use that reflect updated research and thinking on how three common substances affect the brain. First, Caffeine Withdrawal has been added as a diagnosis to respond to the reality of the physical, emotional and psychological effects that can occur in some people related to abruptly stopping or significantly reducing caffeine intake.
Along a similar vein, evidence shows that THC, the active ingredient in marijuana, can produce increased tolerance and other signs of a physical/emotional dependence. This means that moderate or heavy users can exhibit physical, emotional and psychological signs and symptoms of withdrawal when use of the substance is abruptly discontinued. Cannabis Withdrawal was added as a diagnosis to accommodate this clearer understanding of the realities of Cannabis use..
Finally, while the DSM-IV-TR had diagnoses for Nicotine Dependence and Nicotine Withdrawal, there was not a way to code for Nicotine Abuse separate from dependence and withdrawal. This represented a different formulation for this substance as opposed to most of the other addictive substances that were coded in the DSM.
The DSM-5 changed this formulation to make the coding for tobacco use consistent with the coding for other addictive substances. In the DSM-5, problems with the use of tobacco products are now coded as Tobacco Use Disorder, with specifiers to note if the problem is Mild, Moderate or Severe, In early remission or In sustained remission, or if the client is On maintenance therapy (e.g., nicotine patch) or In a controlled environment, where access to tobacco is restricted.
There is a note in the DSM-5 concerning coding for a Tobacco User Disorder that is co-morbid with a tobacco withdrawal diagnosis or a tobacco-induced sleep disorder. Under ICD-10, it is not necessary to add the diagnosis for Tobacco User Disorder when either of these two other diagnoses is present. The code numbers to the right of the decimal point (e.g., F17.208) for these two tobacco-related disorders will note the presence of a tobacco use disorder, as well as whether the level of severity of the use is moderate or severe.
The DSM-5 also clarifies that “it is not permissible to code a comorbid mild tobacco use disorder with a tobacco-induced sleep disorder.” (DSM-5, 2013)
Introduced: Binge Eating Disorder
In the DSM-5, Binge Eating Disorder (ICD-10: F50.8) was changed from a diagnosis in need of further study - in the DSM-IV-TR - to a validated and substantiated diagnosis, describing a condition in which a client engages in episodes of binge eating with an accompanying sense of a lack of control. In order to qualify for this diagnosis, the client must exhibit binge eating episodes an average of at least once a week for a period of three months. In the DSM-IV-TR, the criteria for this diagnosis included an average of two bingeing episodes per week for a period of at least six months.
This disorder is differentiated from a diagnosis of Bulimia Nervosa by the absence of inappropriate compensatory behaviors – like purging or the use of laxatives. It is important to note that the DSM-5 diagnosis, 307.51, is identical to the DSM-5 diagnosis for Bulimia Nervosa, so when recording the diagnosis it is important to write out in full the name of the disorder. However, when the transition to the ICD-10 has been completed, the new diagnostic code for Binge Eating Disorder (ICD-10: 50.8) will be different from the code for Bulimia Nervosa (ICD-10: 50.2).
In order for this diagnosis to be considered, the binge eating behaviors must also demonstrate at least three of the following:
- Eating more rapidly than normal.
- Eating until feeling uncomfortably full.
- Eating large amounts of food when not feeling physically hungry.
- Eating alone because of being embarrassed by how much one is eating.
- Feeling disgusted with oneself, depressed, or very guilty afterward.
There are two important specifiers to note when recording a diagnosis of Binge Eating Disorder. The degree of severity, from mild to extreme, should be noted based upon the number of binge episodes per week (mild = 1-3 episodes, moderate = 4-7, severe = 8-13 and extreme is 14 or more). It should also be noted if the disorder is in full remission (no binge episodes) or partial remission (less than one episode per week).
Introduced: Gambling Disorder
There are several additions to the DSM-5 that raised some controversy. Gambling Disorder (ICD-10: F63.0) is one of them. It has placed within the section covering Substance-Related and Addictive Disorders. According to the APA, “(t)his change reflects the increasing and consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse and that gambling disorder symptoms resemble substance abuse disorders to a certain extent.” (APA, 2013)
The gambling behavior must accompany clinically significant impairment or distress, and must be separate from a manic episode. There are 9 criteria that must be examined, and a client must exhibit at least four of them within a twelve month period. These are:
- Needs to gamble with increasing amounts of money in order to achieve the desired excitement.
- Is restless or irritable when attempting to cut down or stop gambling.
- Has made repeated unsuccessful efforts to control, cut back, or stop gambling.
- Is often preoccupied with gambling.
- Often gambles when feeling distressed.
- After losing money, often returns another day to get even.
- Lies to conceal the extent of involvement with gambling.
- Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.
- Relies on others to provide money to relieve desperate financial situations caused by gambling.
There are also three specifiers that may accompany this diagnosis to provide greater clarity about the nature and severity of the problem. It may be noted whether the gambling is: (1a) Episodic or (1b) Persistent; (2a) In early remission or (2b) In sustained remission; and (3a) Mild (4-5 criteria met), (3b) Moderate (6-7 criteria met) or (3c) Severe (8-9 criteria met).
Introduced: Disruptive Mood Dysregulation Disorder (DMDD)
Another addition to the DSM-5 that has generated some degree of controversy is Disruptive Mood Dysregulation Disorder (ICD-9: 296.99; ICD-10: F34.8). This diagnosis was placed among the depressive disorders and was developed, according to the APA, to “address concerns about potential overdiagnosis and overtreatment of bipolar disorder in children”. (APA, 2013) This diagnosis is to be used “for children up to 18 years of age who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol.” (APA, 2013)
The symptoms that substantiate this diagnosis include temper outbursts manifested verbally or behaviorally that are out of proportion in intensity or duration to what is warranted by the circumstances, inconsistent with the developmental level of the child, occurring three or more times, on average, per week for more than 12 months, and accompanied by a mood of persistent irritability and/or anger between the temper outbursts.
This diagnosis should not be made if the temper outbursts occur in the midst of a major depressive episode, or are better explained by another disorder, such as autism spectrum disorder, post-traumatic stress disorder, separation anxiety disorder, or persistent depressive disorder. It should also not be made if the symptoms are reflective of substance use or another medical or neurological condition.
This diagnosis is not to be made for the first time before age 6 or after age 18, nor made concurrently with Intermittent Explosive Disorder, childhood onset Bipolar Disorder (BD) or Oppositional Defiant Disorder (ODD). DMDD is considered a more severe condition than ODD, and it includes the range of emotional and behavioral elements seen in ODD, plus additional elements as well. Therefore, if a dual diagnosis is being considered, DMDD should be the only diagnosis used.
DMDD is distinguishable from Bipolar Disorder in that BD occurs in discrete episodes, whereas DMDD is more ongoing and persistent. DMDD is distinguishable from Intermittent Explosive Disorder in that DMDD presents with a persistently irritable or angry mood between temper outbursts with a duration of at least 12 month while Intermittent Explosive Disorder does not present with a persistently irritable or angry mood between outbursts and requires just a 3-month period of duration in order to warrant a diagnosis.
Criticism of this diagnosis was most pointedly leveled by Allen Frances, MD, the psychiatrist who headed the committee to develop the DSM-IV-TR. He expressed concerns that this diagnosis would turn temper tantrums into a mental disorder and lead to increased over-medication of children. (Frances, 2013)
Introduced: Hoarding Disorder
Hoarding Disorder (ICD-10: F42) is a new diagnosis in the DSM-5, located among the group of obsessive-compulsive disorders that includes trichotillomania and two other new disorders of a similar nature that were added in this grouping. In discussing this disorder, the APA notes that while hoarding behaviors can occur in clients who meet the criteria for a diagnosis of obsessive-compulsive personality disorder or OCD, there is also evidence for a separate diagnosis for clients who do not meet the criteria for these diagnoses, but whose central symptoms only consist of problems “discarding or parting with possessions due to a perceived need to save the items and distress associated with discarding them.” (APA, 2013)
Introduced: Excoriation (Skin Picking) Disorder
Excoriation, or Skin Picking, Disorder (ICD-10: L98.1) is another addition to the DSM-5. It is very similar in nature to Trichotillomania (Hair Pulling Disorder), but instead of manifesting as a compulsive urge to pull out one’s hair, its sole manifestation is a compulsive urge to pick at one’s skin. It typically results in skin lesions and accumulating damage to the skin. To classify as a diagnosable condition, it must result in clinically significant distress or impairment in social, occupational, or other important areas of functioning.
For this disorder to be warranted, the urge to pick at one’s skin must not be attributable to the physiological effects of a substance such as cocaine, or to another medical condition, such as scabies. Symptoms cannot be better explained by another mental disorder, such as tactile hallucinations attributable to a psychotic disorder or body dysmorphic disorder, nor be representative of self-injurious behaviors accompanying certain anxiety or depressive disorders.
Part II: Disorders Introduced that are More Typically the Domain of Other Health Professionals to Assess and Diagnose
Introduced: Psychological Factors Affecting Other Medical Conditions
Most Appropriate Personnel to Initiate Diagnosis: Medical and Psychiatric in Conjunction with Mental Health Professionals
There are a number of situations in which psychological and emotional factors can trigger or exacerbate pre-existing medical conditions (e.g., asthma that is triggered or aggravated by the presence of anxiety). In such cases, it is not sufficient simply to note the medical condition and ignore the contributions of the psychological or emotional factors that affect the course of the medical problem. A comprehensive diagnosis in such an instance would include a new diagnosis in the DSM-5, Psychological Factors Affecting Other Medical Conditions (ICD-10: F54).
This diagnosis should only be used where there is a clearly established medical condition, and where there is clear evidence that psychological/emotional factors are have an impact on the course of the medical condition. The complete diagnosis for such a patient would list the medical condition first, then add the reference to the psychological factors with this newly introduced diagnosis. Only a medical professional can ultimately rule whether the exacerbation of the medical condition is from a deterioration of the client’s physical state. This diagnosis is most likely initiated by a physician or other medical professional with the requisite knowledge. However, this is an instance in which a mental health professional’s more intimate knowledge of the client’s day-to-day mental/psychological/emotional functioning can be very useful in reaching a full and correct diagnosis.
If this diagnosis is used, there are specifiers to denote the level of severity present in the interaction of the psychological with the physical:
Mild: Increases medical risk
Moderate: Aggravates underlying medical condition
Severe: Results in medical hospitalization or emergency room visit
Extreme: Results in severe, life-threatening risk
Introduced: Premenstrual Dysphoric Disorder (PDD)
Most Appropriate Personnel to Initiate Diagnosis: Medical and Psychiatric
Still another controversial addition to the DSM-5 is Premenstrual Dysphoric Disorder (ICD-10: N94.3). This diagnosis is now placed among the depressive disorders and designed to address marked changes in mood and behaviors that occur as the result of the hormonal changes accompanying a woman’s menstrual cycle. At least five symptoms in two criterion areas (criterion areas B and C) must be present, and the onset, reduction and remission of the symptoms must coincide with a women’s movement through the period leading up to and through the menstrual cycle.
Criterion area B include such items at affective lability, irritability and anger, depressed mood and feelings of hopelessness, and anxiety, tension or feelings of being keyed up or on edge. Criterion area C includes decreased interest in usual activities, difficulty in concentration, lethargy, changes in appetite, changes in sleep patterns, a sense of loss of control, and marked physical symptoms such as bloating, breast tenderness, weight gain and joint or muscle pain.
At least one symptom from criterion area B and at least one symptom from criterion area C must be present for this diagnosis to be warranted, plus any additional three or more symptoms from either criterion area.
To use this diagnosis, the “symptoms must be associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others” (DSM-5, 2013) The symptoms must also not be attributable to substance use or another medical condition, and must not be simply “an exacerbation of the symptoms of another disorder, such as depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder.” (DSM-5, 2013)
Introduced: Substance/Medication-Induced Obsessive-Compulsive and Related Disorder
Most Appropriate Personnel to Initiate Diagnosis: Medical and Psychiatric
There are a number of brain areas implicated in the development of obsessive and compulsive symptoms and behaviors. When these brain areas are affected by some form of neurological damage due to trauma or disease processes, or disturbed by the addition of certain substances or medications, neurologically driven changes in behavior can occur.
For example, a primary medication for patients with Parkinson’s Disease is a substance called L-Dopa. This medication can produce obsessive-compulsive behavioral effects, including uncontrollable gambling or sexual behaviors. Likewise, long-term cocaine and amphetamine users can develop a variety of compulsive behaviors like scratching, skin picking and hair pulling due to the disruption of the neurotransmitters at specific brain sites associated with obsessive and compulsive behaviors.
In such instances, a diagnosis of Substance/Medication-Induced Obsessive-Compulsive and Related Disorder (ICD-10: F14.xxx and F15.xxx) would be used. In most instances, it is preferable for this diagnosis to be initiated by a medical professional: psychiatrist, addictionologist or other MD.
The DSM-5 clarifies that it would typically not be used as a diagnosis when there is a primary diagnosis of substance intoxication or substance withdrawal. The obsessive-compulsive symptoms, unless they are severe, would not be singled out from among the list of possible effects of substance intoxication and substance withdrawal, so there would be no need to add this diagnosis to the clinical picture.
However, if the obsessive and compulsive symptoms predominate in the clinical picture and are sufficiently severe to warrant clinical intervention, then a decision may be made to clarify the diagnostic picture by adding to the diagnosis that is written out a specifier noting the Substance/Medication-Induced Obsessive-Compulsive and Related Disorder.
In such cases, the substance abuse disorder (e.g., Cocaine intoxication) should be listed first – including other relevant specifiers, such as those noted in paragraphs below - followed by the word “with”, followed by “Substance-Induced Obsessive-Compulsive and Related Disorder”. (E.g., Cocaine intoxication, with comorbid cocaine use disorder and perceptual disturbances (ICD-10: F14.222) with Substance/Medication-Induced Obsessive-Compulsive and Related Disorder)
ICD-10 diagnostic numbers create somewhat better clarity concerning which substance is creating the symptoms, distinguishing between amphetamine or other stimulant usage (F15.xxx), cocaine (F14.xxx) and other or unknown substance (also F14.xxx).
ICD-10 creates additional clarity by using the three digits to the right of the decimal point. These three digits clarify whether the symptoms are occurring with co-morbid use/misuse of the substance in question, including whether that use is mild (XXX.188) or moderate or severe (xxx.288), or without co-morbid use of the substance in question (xxx.988). This latter instance would be the case when a client had a one-time heavy use of a substance that created the obsessive-compulsive symptoms, but no further and ongoing use is occurring.
For proper diagnostic use, the obsessive or compulsive symptoms must appear during or soon after substance intoxication or withdrawal for drugs, and after exposure for a medication. It must also cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
There are also specifiers that you should use to address when the symptoms appear: With onset during intoxication, with onset with withdrawal, and with onset after medication use.
There are also a couple of occasions when the diagnosis may serve as a stand-alone item. First, if the medication causing the symptoms is a non-addictive substance, such as L-Dopa. Be sure to note this information when the diagnosis is written out in full. Second, if the obsessive-compulsive symptoms are present separate from the periods of intoxication or withdrawal, then the diagnosis is clinically appropriate as a stand-alone item.
Introduced: Obsessive-Compulsive and Related Disorder Due to Another Medical Condition
Most Appropriate Personnel to Initiate Diagnosis: Medical and Psychiatric
In a way that is very similar to the triggering of obsessive and compulsive behaviors by the presence of certain drugs or medications, there are medical conditions that can alter the areas of the brain that are involved in OCD behaviors. The DSM-5 added a new diagnosis to accommodate this knowledge, Obsessive-Compulsive and Related Disorder Due to Another Medical Condition (ICD-10: F06.8).
In order to use this diagnosis, the specific medical condition responsible for the OCD behaviors must be included in the diagnosis when it is written out (e.g, F06.8 obsessive-compulsive and related disorder due to cerebral infarction). The DSM-5 also clarifies the ICD-10 code for the medical condition (e.g., Cerebral Infarction,ICD-10: I69.398) must be listed ahead of the diagnosis that lists the OCD symptoms created by the medical condition.
For this reason, it is unlikely that most mental health clinicians would originate this diagnosis. The nature of the medical condition must be assessed by a medical professional qualified to make that determination. If this condition is noted, it will be accompanied with the specifiers that clearly state how the OCD behaviors appear. These are the options that clinicians may note:
With obsessive-compulsive disorder-like symptoms (Akin to symptoms of OCD, e.g., hand washing, ritualistic behaviors)
With appearance preoccupations (Akin to body preoccupation as in Anorexia or Bulimia Nervosa)
With hoarding symptoms (Akin to symptoms of Hoarding Disorder which has been added as a diagnosis in the DSM-5)
With hair-pulling symptoms (Akin to symptoms of trichotrillomania)
With skin-picking symptoms (Akin to symptoms of Skin-Picking Disorder which has been added as a diagnosis in the DSM-5)
Introduced: Mild neurological disorders, various etiological subtypes
Most Appropriate Personnel to Initiate Diagnosis: Medical and Psychiatric
DSM-5 added the possibility of recording mild neurocognitive disorders in order to distinguish earlier and less profound manifestations of neurocognitive deficits from more advanced and more profound levels of the disorders. The DSM provides the differentiating criteria to help medical personnel make accurate diagnoses of both the subtype of the Neurological Disorder and the level of severity. It also notes whether the disorder presents with or without behavioral disturbance.
These diagnoses are initiated by competent medical professionals only. While mental health clinicians must 1) understand the implications of these disorders for successful interventions in the lives and well being of their clients; and 2) record the diagnoses in client records once the conditions have been assessed by other medical personnel, they should refrain from initiating these diagnoses on their own.